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Servicer Profile Questionnaire


We would like to know more about you. Please provide us with the following information so we can better assist and evaluate your request. Once you have completed all fields remember to click SUBMIT


First Name *
 
Last Name *
 
Phone Number *
 
Your Position *
 
Company Name *
 
Address *
 
City *
 
State *
 
Zip Code *
 
Business Phone *
 
Business Email *
Please retype the email for verification:
 
Web site
 
Coverage Area (E.x. Central New York)
 
Do you service MAJOR APPLIANCES?
Electric
Gas
Sealed Systems
Do you service TELEVISIONS?
On Site Repair
Provide Installation Services
Facilitate Exchanges
Do you service MICROWAVE OVENS?
On Site Repair
Willing to learn
Do you service ADJUSTABLE/ELECTRONIC BEDS?
Yes
Willing to learn
Do you service MEDICAL/NURSE’S CARTS?
Yes
Willing to learn
Do you service MOBILE COOLING?
Yes
Willing to learn
Other Capabilities
Comments and Questions
File Attachement